A TIMELINE

OF THE

HISTORY OF NEPHROLOGY

A joint project of

The International Association for the History of Nephrology

The ERA/EDTA

And the Panhellenic Society for the History and Archaeology of Medicine

By Athansios Diamandopoulos

“We have come to understand that we are who we are

is also who we were”

John Quincy Adams (1767-1848)

 AUTHOR INDEX

1. Hippocrates, 5th cent. BC

2. Aristotle, 4th cent. BC
3. Erasistratus, 3rd cent. BC
4. Philo Judeus 1st cent. BC-1st cent. AD
5. Dioscurides, 1st cent. AD
6. Galen, 1st - 2nd cent. BC
7. Rufus Ephesus, 1st - 2nd cent. AD
8. Arêtes Cappadociensis, 2nd cent. AD
9. Pseudo-Galen, 2nd cent. AD
10. Alexander Aphrodisiensis, 2nd-3rd cent. AD
11. Oribasius Pergamenus, 4th cent. AD
12. Nemesius of Emesa, 4thcent. AD
13. Palladius, 5th cent. AD
14. Alexander of Tralles, 6th cent. AD
15. Aetius Amidenous, 6th cent. AD
16. Stephanus of Alexandria, 7th cent. AD
17. Paul of Aegina, 7th cet. AD
18. Theophilus Protospatharius, 7th cent AD (?)
19. Stephanus of Athens, 9th-10th cent AD (?)
20. Damascius, 9th-10th cent AD (?)
21. Michael Psellus, 11th cent. AD
22. Symeon Seth, 11th cent. AD
23. Johannes Apocaucus, 13th cent. AD
24. Nicolaus Myrepsus, 13th cent. AD
25. Johannes Zacharias Actuarius, 13th cent. AD
26. Nicephorus Vlemmydes, 14th cent. AD

Before reporting the topics of Nephrology that were dealt with by Ancient Greek and Byzantine writers, it would be
worth commenting on the etymogy of the two commonest words used by them in their relevant treatises

a) The word Urology has been explained as a compound name of the Latin word urine and the Greek word logos,
the latter meaning "knowledge". However there exists in Greek the word uron, meaning the urine. Hippocrates
had already employed the word in his work "Peri uron" that is "On urines". A theory closer to the truth recognizes
both the Latin and the Greek words as derivatives of the Sanscritic word vari, meaning water and consequently the
urine.
b) The word nephros (in Greek: νεφρός) whence the compounds nephrology, nephrological etc derive, comes from
the Greek word nephos (νέφος) meaning cloud. The Latin equivalent is “nebula”. Both the Greek and the Latin
word derive from the Sanskrit word “nabbas”, meaning heaven. The use of the same word both for a cloud and for
a kidney is based on the observation that both produce a liquid; i.e. rain from clouds and urine from kidneys.
 1.

Author Hippocrates and corpus Hippocraticum (5th cent. BC and onwards)

Images
(SEE ATTACHED FILES)
Anatomy Describes the growing out of the kidneys from renal arteries, branches of the abdominal aorta,
Pathology and the parallel direction of the nerves. He correctly defines the aorta as originating in the
heart. He observed the anatomical connection of spermatic arteries with the kidneys, a fact
that led to the notion that the sperm is initially created inside the kidneys, is then delivered via
spermatic vessels to the testicles and finally outside the body. He remarked about the similar
shape of both kidneys and likened their colour to that of apples. The calyxes and pelvic cavity
were observed and commented on. He also described the ureters as descending from the
kidneys and ending at the bladder.
He described the granular and sticky texture of the kidneys and the excess of humidity in their
interior. He found their temperature was below mean human body temperature.
Physiology Renal vein vessels transfer blood with waste liquid product of metabolic reactions to the
kidneys. There, it departs from the blood, which returns purified, to the whole body. The filtrate,
excreted from the renal granules, is then directed to the bladder via the ureters, where it is
further clarified and excreted through the urethra. Hesitantly, he considers the kidneys as “not
alien to the excretion of urines”.
Chemistry
Disease Hippocrates links various urological symptoms with diagnosis and prognosis. In his work
“About inner sufferings, he reported the symptoms and incidence of renal lithiasis and blamed
these on drinking water when it has a high concentration of salts and poor milk quality. Urine
retention accompanied by sudden renal pain is a symptom of passing stones or sand-like
material. He considered gout rare before puberty. Those in the 14 to 40 yr age group were
deemed more susceptible to various diseases, amongst which those affecting the kidneys.
Subsequently, till the age of 63 the appearance of renal problems is attributed to a relapse of a
previous disease. He stated that chronic renal diseases are never cured if the patient is older
than fifty years old. He used the term “nephritic” to describe patients with a variety of renal
ailments, like strangury, anuria and haematuria. He usually blamed for them generalized
infections, and over-consumption of starch. There is a description of recurrent renal abscesses
combined with deformity of the lower spinal column, a syndrome reminiscent of renal and bone
tuberculosis (Pot syndrome). He speculated that when hair-like fleshy elements (blood-casts)
are found in urine this is evidence of a renal disease, while spontaneous haematouria
indicates renal vessel rupture. When a nephritic patient presents with bleeding from
haemorrhoids this is a good omen (lower blood pressure?). When there are bubbles on the
urine surface (due to proteinuria?) this is an indication of renal disease chronicity.
Therapy
Technical
General Historians accept that Hippocrates actually existed, based heavily on a passage in Plato’s
Comments writings, in which his contemporary philosopher acknowledged him as an excellent doctor.
There is also a coin from Cos, struck during his era with his name on it. He was born circa 460
BC on the island of Cos, at the Eastern shore of the Aegean Sea and became a famous
physician and teacher of medicine. All other biographical information available today must be
based on many years of oral tradition and are thus not indisputably reliable. These include his
visit to Sicily and his refusal to treat Xerxes, the king of Persia.
 The Hippocratic or Coan school that formed around him was of great importance in placing
medicine on a strictly scientific plane, based on objective observation and critical deductive
reasoning. He was held in high esteem by the medical profession and the educated classes
since his lifetime till today. There is however a paradox regarding the criteria upon which this
estimation is based. Till the Enlightenment, when his purely medical ideas were more or less
believed and societies were deeply religious, his religious beliefs were not discussed nor even
the fact that he was a pagan was disturbing. Moreover the Christian Church somehow adopted
him as a semi-Christian pro-runner of Christian beliefs. From his moral teachings, the Oath in
particular was reverent. The best-known quotation from Hippocrates’ works concerning urology
is the passage from the Hippocratic Oath forbidding lithotomy.
Today, that his medical teaching has been greatly surpassed by modern medicine, he is
acclaimed as the one who separated religion from medicine excluding any divine interference
from the cause or treatment of any disease. In reality, the current agnostic or even godless
societies claim Hippocrates as one of their own. The father of medicine was a rather religious
man. He clearly accepted the divine superiority towards the medical profession, he supported
that diseases are caused by gods, but strictly on the understanding that gods created Nature,
thus, creating the diseases as well, and started the famous Oath, whose authorship anyway, is
dubious, with an invocation to the gods. What he strictly rejected was charlatanism and the
idea that gods sent particular diseases to a person as punishment, avoidable through
incantations and donations. However, this eclectic stance on the matter, if seen through a
narrow-minded viewpoint, offers arguments to both sides. Hence, it can aptly said of his
teaching that it is perpetuated ‘loaded by the mud of his enemies and the rust of his friends’.

Biography Hippocrates, c.460-c.370 BC, Greek physician, is recognized as the Father of Medicine. He
was born on the island of Cos, to a family of famous physicians, that claimed Asclepios (Latin:
Aesculapius), the God of Medicine, as their ancestor. Worth mentioning that Asclepios himself
had been initially a mortal, extremely competent physician, whose two sons participated in the
Trojan War and are reported in Homer’s Iliad. He was later deified, but his mortal descendants
practiced medicine for centuries afterwards, calling themselves “Asclepiads”. Hippocrates
originated from such a family. He had studied under his father, a physician, and had travelled
extensively, mainly to the shores of Marmara in Propontis, to North and Central Greece and
then to Athens, practising medicine wherever he went. During his travels, he kept detailed
reports of patients he treated, a kind of case notes. These were later gathered in a book in the
Corpus Hippocrataticum, called Epidemiae, (a compound word from the Greek words epi
meaning in this instance going towards and demos meaning the registered population of a
place) and broadly speaking it is equivalent of visiting various towns, and it should not be
confused with the current meaning of “epidemic”, signifying an infectious agent “visiting” an
area. He later returned to practice, teach, and write at Cos. It is almost certain that he died in
the area of Larissa, in Central Greece, the legendary birthplace of Asclepios. His tombstone
there was accidentally found and kept at the house of the local pasha. Several visitors had
seen and described it and its epigram during the 19th century, but it is now lost.

Hippocrates followed the contemporary belief that disease resulted from an imbalance of the
four bodily humours; namely, blood, black bile, yellow bile and phlegm. In this theory he had
been influenced by similar and older Mesopotamian and Egyptian beliefs. He maintained that
the disturbance was influenced by outside forces and that the humours were secretions of
various organs. According to his doctrine of "the healing power of nature", or in Latin, vis
 medicatrix naturae, the body contains within itself the power to rebalance the four humours
and heal itself (physis). He believed that the goal of medicine should be to build the patient's
strength through an appropriate diet and hygienic measures, resorting to more drastic
treatment only when the symptoms showed this to be necessary. Hippocratic medicine was,
humbly, very kind to the patient, sterile and gentle whenever possible. For example, only clean
water or wine was ever used on wounds, though "dry" treatment was preferable. This was in
contrast to the contemporary Cnidian school, which stressed detailed diagnosis and
classification of diseases to the point of ignoring the patient. Hippocrates probably had an
inkling of Mendelian and genomic factors in heredity, because he noted not only many of the
signs of disease but also that symptoms could appear throughout a family or a community, or
even over successive generations.
Further reading

Author Aristotle, 4th cent. BC

Images
Anatomy His observations about the location and shape of the kidneys are similar to those of
Pathology Hippocrates. He (wrongly) stated that the right kidney is higher than the left, but he (rightly)
described the perirenal fat. He further elaborated on the path of the renal vessels inside the
kidneys. He rightly commented on the “consumption” of the arterial capillaries in the renal
parenchyma and not in the cavity. We note an accurate description of the anatomical
relationship between the abdominal aorta and the vein and their bifurcation. He also
described the relationship between the renal vessels and those ending in the bladder.
Physiology He considers the kidneys as not absolutely necessary for the excretion of waste products.
Firstly, because there are animals who excrete this product through their lungs and skin, like
some reptiles, and secondly because even those who have kidneys use them to pre-purify
the blood and send the filtrate to the bladder where it is perfectly turned to clear urine and
excreted. Thus, kidneys are assistants to the work of the bladder.
Chemistry
Disease He linked sexual over-activity to renal weakness and he reported that the kidneys frequently
appear full of stones and abscesses.
Therapy
Technical
General
Comments
Biography
Further reading

Author Erasistratus, 3rd century BC

Images
Anatomy He introduced the word “parenchyma” which we use even to day, in attempt to explain the rich
Pathology blood supply of the kidneys. He could not apparently see the glomeruli and he assumed that
the blood was purring out and beside the renal arterioles, in Greek “parenchyneto”. .
Physiology He was the first to state that urine is formed in the Kidneys, but Galen later challenged this
pioneering statement. He also experimented with a hen, which he enclosed in a cauldron,
trying to estimate the transpiration and he succeeded to it.
Chemistry
Disease
Therapy
Technical
General
Comments
Biography Greek physician and anatomist, was born around 250 BC, his year of death being uncertain.
He founded the school of anatomy at Alexandria. He is credited with being the first to
distinguish between motor and sensory nerves. He traced veins and arteries to the heart, and
named the trachea and the tricuspid valve of the heart. He was the first major exponent of the
theory of pneuma.

Further reading

4
Author Philo Judeus, 1st cent. BC

Anatomy He correctly suggested that the role of perirenal fat is to support and protect the kidneys, but
Pathology incorrectly hypothesized that it also protects the ureters to deliver unobstructed sperm to the
genitals.

Physiology The kidneys are sanguineous pools where the clearing of the liquid excrements takes place.

Chemistry
Disease
Therapy
Technical
General
Comments
Biography A Hellenised Jew of Alexandria, and a very famous historian and writer, born about 30 B.C,
died about 45 A.D. He was a great mystic and his works abound with metaphysics and
noble ideas, while in esoteric knowledge he had no rival for several ages among the best
writers.
Further reading

5
Author Pedanius Dioscurides, 1st cent. AD
(SEE ATTACHED FILES)
Anatomy
Pathology
Physiology
Chemistry
Disease
Therapy Dioscurides’ celebrated work ‘Materia Medica’ includes many substances that can be used
for renal ailments. Namely, he recommends 12 mineral, 16 animal, and 48 liquid and 192
vegetable products. Only three examples are presented here:

Kyklaminos: Cyclamen europaeum: Cyclamen, sowbread

This herb’s name (cyclamen means “circle” in Greek) derives from its bulb-like, underground
stem. Dioscurides suggested its use as a purgative, antitoxin, skin cleanser, and labour-
inducer. When used as a purgative, juice from the tuberous rootstock was applied
externally, either over the bowels and bladder region or on the anus. Dioscurides also
mentioned its use as an aphrodisiac. Many English farmers called Cyclamen “stag-truffle” or
“sowbread” as they often observed deer and swine digging up and eating the roots. The
variant ‘Colchicum Autumnale’ was recommended for the treatment of gout, and the drug
colchicin derives from this.

Strychnos Megas Kepaios: Solanum nigrum: Black Nightshade

A relative of the notorious Atropa belladonna, or Deadly Nightshade, the Black, or Garden,
Nightshade is potentially harmful, but its poison is relatively mild. Dioscurides recommended
its leaves for treating skin diseases. He also suggested a decoction of the plant’s leaves for
earaches, indigestion, and internal bleeding as well as colics.

Artemisia

An early medical reference to it was made in Materia Medica, wherein its properties as a
warming, drying and purgative drug are described. The plant was also called oxetesia,
ephesia, anactorios, sozusa, lea, lycophrys, sanguis hominis, chrysanthemon, herba regia,
rapium, tetrabageta, ponem, and zuoste. It was synonymous and/or likened to absinth. It
was recommended for many diseases such as parasites of the bowel, kidney stones and
intended miscarriage of dead embryos.

Animal products

We have traced several nephrological drugs of animal origin in Dioscurides's Materia

Medica. They range from the common, e.g. earthworms, to the exotic, e.g. camel's milk.

Mineral products

Twelve minerals and fossils were traced, which were prescribed for anuria, dysuria, colic,
bladder lithiasis and gout. These were the Lithoi (stones): Haematite, Gagates (Fossil
Bitumen), Ioudaikos (Fossil Spines of Sea-Urchins), Lithos Spongon (Sponge-Stones),
 Terra Samia, Geodes, Asios, Korallion (Isis Nobiblis), Alkyonion, Ales (Salt), Theion
(Sulphur) and Burned Bricks.
Technical Dioscurides accurately describes all the procedures for producing the drugs named in
Materia Medica. These included the drying, boiling, solidifying, mixing with wine, water, milk,
honey or other substances the various therapeutic agents.
General The oldest known copy of his work is the Juliana Anicia Codex (ca. 512 A.D.), housed in the
Comments Austrian National Library in Vienna. Listed as Codex Vindobonensis Medicus Graecus 1., it
is better known as “Vienna Dioscurides,” the oldest and most valuable work in the history of
botany and pharmacology. It is certain that a Byzantine artist illustrated Dioscurides’ codex
for presentation to Juliana Anicia, the daughter of Emperor Anicius Olybrius, on the
inauguration of a temple she had erected in Constantinople. The choice of the gift was
probably compatible with Anicia’s perception of herself as heiress of king Solomon. The
artist seems to have based his work on illustrations from the Rhizotomicon of Crateuas of
Pergamon (1st century B.C.), as well as other artists. It had been extensively copied in both
the East and the West, to such an extent that many of the illustrations were eventually
distorted and the plants are not recognizable in nature.
Although the work is usually called an herbal, in reality it contains pharmaceutical
information for all types of drugs. Thus, the first volume deals with aromatics (e.g. oils,
gums); the second, with living creatures, fats, cereals, and herbs; the third, with roots; the
fourth, with "other herbs and roots"; and the fifth, with wines and vines. In total, Dioscurides
described about 1,000 remedies, with almost 5,000 uses, using approximately 600 plants
and plant products, as well as a few animal products and minerals. His work remained in
use until about CE 1600. Unlike many classical authors, his books were not "rediscovered"
in the Renaissance, because they never left circulation. The Materia Medica was often
reproduced in manuscript form through the centuries, often with commentary on
Dioscurides' work and with minor additions from Arabic and Persian and other sources.
Some editions were alphabetized for quick reference, which made his works a type of early
medical dictionary.
Biography Pedanius Dioscurides (c. 40 in Anazarbus, Cilicia - c. 90) was an ancient Greek physician,
pharmacologist and botanist who practiced in Rome during the rule of Nero. He was from
Anazarbus, a small town near Tarsus in what is now south-central Turkey. Reputably, he
was a surgeon with the army of the emperor so he had the opportunity to travel extensively
seeking medicinal substances from all over the Roman and Greek world. Dioscurides is
famous for writing a five-volume book ‘Peri Yles Iatrikes’ which was later translated into
Latin as De Materia Medica that is a precursor to all modern pharmacopeias.
Further reading Gunther R., The Greek Herbal of Dioscurides, Illustrated by a Byzantine A.D. 512 -
Englished by John Goodyer A.D. 1655 - Edited and first printed A.D. 1933, University Press,
Oxford, Book I, recipe: 34, 35, 36.
 6

Author Rufus Ephesius, 1st – 2nd cent. AD

Images

Anatomy He describes the location of the kidneys, the ureters and the urethra, insisting that we
Pathology should use the word ureters exclusively for the tubes that connect the kidney with the
bladder and not for the urethra also, as was reputably done by others.
Physiology
Chemistry
Disease He wrote the most extensive treatise on Renal Diseases in Antiquity. From the very
beginning, he differentiated between the acute and spectacular symptoms of the lower
genitourinary tract afflictions, which occur more frequently in younger patients, and the
chronic, salient upper tract diseases that afflict older people. He elaborated on infective
diseases of the tract, describing their symptoms and - occasionally fatal - outcome. In a very
interesting case, he describes a renal abscess evacuating itself spontaneously in the bowel.
In parallel, he also describes renal stones and their symptoms in detail, standing upon the
impact of age, the season of the year, diet, and way of living. He described a disease
(apparently chronic renal failure) with renal sclerosis, stating that it is chronic, without noisy
symptoms, resulting in cachexia, lethargus, and generalized oedema. He suggests (with
foresight) that haematouria is due to a widening of the renal tissue, hence the kidneys
cannot filter urine efficiently, and blood passes with it. Usually, other substances that either
precipitate or float in the urine pass out simultaneously with blood. He also described salient
recurring haematouria. There is a description of an entity reminiscent of mellitus or insidious
diabetes, characterized by heavy polyuria, thirst, emancipation, and death caused by
oedema.
Therapy In his works, Rufus mentions the same cathartic methods with other physicians; namely
venesection, enemas, diuretic drugs, embrocations, cupping, baths and a careful diet. He
adds though an interesting method for perspiration provocation in his work "On the renal
diseases" and in the paragraph "on increased polyuria [urine diarrhoea]": "because it is
good for them to be able to perspire if diuresis stops. The best of all is a steam bath in a
small vat with the head coming out from the top, so that, while the rest of the body is being
heated, one can breathe cool air". He also makes an interesting report in another paragraph
 titled "on renal sclerosis": "One should relieve such people by rubbing and with
embrocations and thermal baths and by prescribing them diuretics and enemas. Thus there
is hope for the movement of the limbs to recover and for them not to fill with liquids".

Technical
General
Comments
Biography
Further reading clendening.kumc.edu/ dc/pc/a.html

Author Galen, 1st – 2nd cent. AD

Images
Galen and Hippocrates
This image represents the split in the classical Greek
medical lineage. The Tree of Life represents the
Healing Arts. On the right is Hippocrates holding in his
right hand a flowering branch symbolizing the vitalist
schools. In the patriarch' s left hand is the text of the
Hippocratic Cannon. To his left is Galen holding the
withered branch of reductionist, mechanistic medicine.
The blooming flower is De Medcina Futura,
Homoeopathy.

Anatomy He made a differential diagnosis between the veins (which do not pulsate and do not have a
Pathology double wall) and the arteries (which contain air, referred to as pneuma. This is a point of his
teachings that had been repeatedly condemned and scorned upon by later doctors.

However, from the careful reading of his works it can safely be assumed that when speaking
about pneuma, Galen meant air-containing blood, i.e. oxygenized air. He also described the
ureters (which do not contain blood and a have different wall structure). He suggested that
there is an ureteropelvic sphincter prohibiting the ureteric reflux and experimentally proved
its existence. However, he repeated the ancient writers’ wrong notion about the higher
position of the right kidney. The blood supply to the kidneys was described in detail. He also
suggested, based on anatomical observations, that the nerves of the kidneys are
outgrowths of the third cerebral vertebra. Galen was the father of the experimental method
in medical investigation, and throughout his life dissected animals in his quest to understand
how the body functions. He also recommended that other doctors practice dissection as a
means of discovery as well as to improve surgical skills. However, because his knowledge
was derived for the most part from animal (principally the Barbary ape), rather than human
 dissection, Galen made many mistakes, especially concerning the internal organs. For
example, he incorrectly assumed that the rete mirabile, a plexus of blood vessels at the
base of the brain in ungulate animals, was also present in humans. In spite of Galen’s
mistakes and misconceptions, his writings reveal an astonishing wealth of accurate detail.

Physiology Galen held that the kidney is one of the organs used for clearing away body waste, like the
intestines, the skin, the nose, the mouth. He indisputably showed that urine is produced in
the kidneys and not in the bladder, by tightening the ureters of an animal and observing that
they became so extended as ready to burst. When he untied them, urine started to pour in
the bladder, a proof that it is formed in kidneys. This simple statement did not satisfy him, so
he tried to explain why this happened. In his usual polemic manner he refuted other writers,
mainly Erasistratus, who albeit accepting the basic thesis that urine was formed in the
kidneys, failed to explain why. Using a complicated series of arguments he hypothesized
that it was not seer gravity that caused the drawing of blood to the kidneys and the
separation of urine from it, but some intrinsic power or property of the kidneys themselves.
For this reason, the arteries supplying the kidneys were very large compared to the organ’s
weight, in order to purify as much blood as possible. However, the blood that enters the
kidney is not solely used for purification, but also as nutrient for the kidney itself. Hence, the
thinner compound of the blood containing the waste toxins (yellow bile) is excreted, while
the thicker one remains in the renal blood steam.

Moreover, to avoid formed urine mixing with blood, the kidneys have a thickly woven
consistency. Worth mentioning are his comments in a polemic against other doctors on
possible blood purification. He said that although we would be able to treat any disease if it
was possible to take all blood out of the body and clean it extra-corporally and then transfer
it back to the body, in reality we could not achieve much, because it was not the blood that
suffered but an internal organ, which would continue to generate impurities and pollute the
blood again. This thesis can rightly be considered as the first theoretical proposal for the
possibility of dialysis and the latter’s inferiority to transplantation. Still, it would have no
practical appliance for another eighteen centuries.

Many of Galen's anatomical and physiological observations were accurate. He proved that
urine was formed in the kidney (as opposed to the bladder which was the common belief).
He correctly identified seven of the 12 cranial nerves, discovered the heart valves,
recognized the contagiousness of tuberculosis, and the possible spread of rabies via dogs.
People such as Vesalius and Harvey finally refuted many of Galen’s notions.
Chemistry
Disease He commented extensively on Hippocrates’ works. He reported kidney damage after
strenuous exercise e.g. horse ridding. The exacerbation of “nephritis” and gout after over-
indulging in food and drink was noted. He commented with insight on the filtrating capacity
of the kidneys, by saying that it is based on the secretion of a serous matter, different from
blood, in the area where minute vessels merge together. While, if this failed, the serous
matter with the waste products is diffused in the whole body, causing oedema. He
differentiates between anuria and retention of the urines, adding that obstruction of the
urinary tract may be caused by stones and also by thrombi created in haemorrhagic and
infective situations. The radiation to neighbouring organs of a pain due to renal disease was
 noted, as well as the differentiating signs between a renal and an intestinal colic. He also
differentiated between pus coming from the kidneys (mixed with urine) and that coming from
the bladder (pure pus). Extremely interesting is the statement that the hair-like sediment of
the urines (casts) is not formed in the renal pelvis but in the renal capillaries (!). Equally
interesting is the statement that haematuria may be due to weakness of the kidneys
themselves to prevent blood from escaping in the urine, or to the blood vessels while the
kidneys remain intact. He hypothesized that the same cause that produces excess of water
- drinking in diabetes - also produces polyuria, which is explained by some “weakness” of
the kidneys. A very rare case of a renal abscess evacuated through coughing was reported,
and explained by free discharge of the pus from the kidney to the venous circulation, then to
the heart and thence to the pneumonic vessels.

Therapy Galen performed many audacious operations that were not again used for almost two
millennia, including brain and eye surgery. He reputably performed an emergency
pericardiectomy to a woman with cardiac tamponate who frequently fainted because of it.
After the operation the patient recovered His favourite subject was the Barbary ape, on who
also performed experimental pericardiectomy.
Technical Galen’s contribution to the evolution of medical statistics is usually ignored. We present here
only one example: “I assert that experience has shown that what has produced a similar
result in three cases can produce the reverse in three others. I say that a thing seen may be
seen exactly as before, and yet belong to those things, which are of both kinds, or to those
things that happen often or to those things that take place but rarely. […] What is to prevent
the medicament that is being tested for having a given effect on two hundred people and the
reverse effect on twenty others; and to prevent that of the first six people who were seen at
first and on whom the remedy took effect, three belong to the two hundred and three to the
twenty without you being able to know which three belong to the two hundred and which to
the twenty, even if you were a soothsayer? … Therefore I say of what has been seen but
once, that is not technical, just as the single grain of wheat is not a perfect heap; but if it is a
thing that is seen many times in the same way, then I call it technical. …”(20)

General Reportedly, he employed twenty scribes to write down his words. In 191, a fire in the
Comments Temple of Peace destroyed some of his records. ("Nature" - Greek physis) - a major reason
why later Christian and Muslim scholars could accept his views. His fundamental principle of
life was pneuma (air, breath) that later writers connected it with the soul. These writings on
philosophy were a product of Galen's well-rounded education, and throughout his life Galen
was keen to emphasise the philosophical element of medicine. Pneuma physicon (animal
spirit) in the brain took care of movement, perception, and senses. Pneuma zoticon (vital
spirit) in the heart controlled blood and body temperature. "Natural spirit" in the liver handled
nutrition and metabolism. Although he was not a Christian, Galen’s writings reflect a belief in
only one god, and he declared that the body was an instrument of the soul. This made him
acceptable both to the fathers of the church and to Arab and Hebrew scholars.

Galen’s works in many ways came to symbolize Greek medicine to the medical scholars of
Europe and the Middle East for the next fifteen centuries. His message of observation and
experimentation were largely lost, however, and his theories became dogma throughout the
West. In the mid-16th century, however, his message that observation and investigation
were required for through medical research began to emerge, and modern methods of such
research finally arose. If the work of Hippocrates represents the foundation of Greek
 medicine, then the work of Galen, who lived six centuries later, is the apex of that tradition.
Galen crystallised the best work of the Greek medical schools, which had preceded his time.
It is essentially in the form of Galenism that Greek medicine was transmitted to the
Renaissance scholars.

Biography The most famous doctor in the Roman Empire was a Greek, named Galen (1st – 2nd century
AD) (Greek: Γαληνός, Galēnos, born in Pergamum. Because in several epigrams a C
followed his name, i.e. Galen C., it was wrongly thought that the famous Roman family of
Claudii adopted him and the C stands for Claudius. In reality, the C. stands for ‘Clarissimus’
meaning ‘Glorious’ in Latin.

His parents gave to Galen an education that prepared him to be a philosopher, but at the
age of 16, he changed his mind and decided to become a doctor. He studied in Greece, in
Alexandria and other parts of Asia Minor and returned home to become chief physician to
the gladiator school in Pergamum. During this time he gained much experience of trauma
and wound treatment. He later regarded wounds as "windows into the body". Galen was
very ambitious and set his sights on Rome. A combination of self-promotion, skill with
otherwise 'incurable' patients, vast knowledge and, as is often the case, good connections
made him well known around town.

An outbreak of plague in Rome forced him back to Pergamum, but in 168-9 he returned to
Italy to serve as physician to Lucius Verus and Marcus Aurelius during a military campaign
in Northern Italy. Galen then went back to Rome with Aurelius to serve as his personal
physician. He would later serve as physician to Aurelius's successors, Commodus and
Septimius Severus.

Further reading Hahnemann on Constitution and Temperament, Chapter One: Constitution, Temperament &
Diathesis

Scarborough J. Galen's investigations of the kidney, Clio Med. 1976,Oct;11(3):171-7

Crombie AC, editor. Galen in: Styles of scientific thinking in the European tradition. London:
Duckworth, 1994:224-225 pp.

Author Areteus Cappadociensis, 2nd century AD

Images
Anatomy
Pathology
Physiology Special attention should be given to Areteus’s remark that, in what we call now a day diabetic
nephropathy, the disease may be located in the kidneys (correct) but it may also be explained
 by some melting of muscles which are then excreted via the kidneys (equally correct).
Chemistry
Disease He repeats earlier writers’ description of renal colics and renal infections. He states that renal
colics, although very painful and spectacular, do not jeopardize a patient’s life. There is a
detailed classification of renal stones according to their size, shape, opacity, location in the
urinary tract etc. However, if they cause urine retention with or without infection, the outcome is
always very serious and, if left untreated, fatal. Again there are detailed descriptions of different
renal abscesses and a very interesting description of diabetic nephropathy with emphasis on
polyuria and polydipsia. He likened the symptoms with those appearing after a biting by the
poisonous snake “dipsas” so called because it causes thirst (dipsa).

He defined gout as a disease appearing in crisis, reinvented the word “diabetes”, described the
urinary tract dilatation secondary to obstruction of the bladder and supported the idea of
physical removal of a renal calculus through exercise.
Therapy He repeats the usual recommendation for various herbal remedies and/or venesection for renal
diseases. An interesting comment of his is the statement that it is very difficult to cure chronic
lithiasis, especially in the old age. Afflicted patients will eventually die carrying their problem.
Hence only alleviating treatment is recommended. Because, if a body has the fertile ability to
deliver stones, it is easier to turn a sterile woman to a mother than to stop the formation of
stones.
Technical
General As a general comment, some fractions of Areteus’s treatise on diabetes and its affliction on
Comments kidneys are presented. However, it must be kept in mind that although Areteus is considered
the first describer of diabetes, Dimitrius of Apammia had briefly reported the disease in the
second century BC. “Diabetes is a strange affection, not very frequent among men, being a
melting down of the flesh and limbs into urine. Its cause is of a cold and humid nature as in
dropsy. The course is a common one, namely the kidneys and bladder, for the patients never
stop making water, but the flow is incessant, as if from the opening of aqueducts. Hence the
disease appears to me to have got the name diabetes, as if from the Greek word which signifies
a siphon, because the fluid does not remain in the body, but uses the man's body as a bladder
whereby to leave it. They stand out for a certain time, though not for very long for they pass
urine with pain, and the emaciation is dreadful; nor does any great portion of the drink get into
the system, and many parts of the flesh pass out along with the urine. The nature of the disease
then is chronic, and it takes a long period to form, but the patient is short-lived if the constitution
of the disease be completely established; for the melting is rapid, the death speedy”.

Moreover, life is disgusting and painful; thirst unquenchable; excessive drinking, which however
is disproportionate to the large quantity of urine for more urine is passed; and one cannot stop
them either from drinking or making water. Or if for a time they abstain from drinking, their
mouth becomes parched and their body dry; the viscera seem scorched up; they are affected
with nausea, restlessness, and a burning thirst; and at no distant term they expire, thirst as if
scorched by fire. The cause of this may be that some of the acute diseases may have
terminated in this; and during the crisis of the disease may have left some malignity lurking in
the part.

But if anyone is bit by the dipsas [a species of viper] the affection induced by the wound is of
this nature; for when the reptile dipsas bites one, it causes an unquenchable thirst. Others do no
 pass urine, nor are their any relief from what is drunk. Wherefore, what from insatiable thirst, an
overflow of liquids, and distension of the belly, the patients suddenly burst.

TREATMENT

The affection of diabetes is a species of dropsy, both in cause and condition, differing only in
the place by which the humour runs. For, indeed, in ascites, the receptacle is the peritoneum,
and it has no outlet, but remains there and accumulates. But in diabetes, the flow of the humour
from the affected part and the melting are the same, but the defluxion is determined by the
kidneys and the bladder; and in dropsical cases this is the outlet when the disease takes a
favourable turn; and it is good when it proves a solution to the cause, and not merely a
lightening of the burden. In the latter disease the thirst is greater; for the fluid running off dries
the body.

But the remedies for the stoppage of the melting are the same as those for dropsy. For the thirst
there is need for a powerful remedy for in kind it is the greatest of all sufferings; and when a
fluid is drunk it stimulates the discharge of urine; and sometimes as it flows off it melts and
carries away with it particles of the body. Medicines then, which cure thirst, are required, for the
thirst is great with an insatiable desire of drink, so that no amount of fluid would be sufficient to
cure the thirst. We must, then, by all means strengthen the stomach, which is the fountain of the
thirst. When, therefore, you have purged with the hiera, use as Epithemes the nard, mastic,
dates, and raw quinces; the juice of these with nard and rose oil is very good for lotions; their
pulp with mastic and dates, form a cataplasm.... But the water used as drink is to be boiled with
autumn fruit. The food is to be milk, and with it cereals, starch, groats of spelt, gruels. Astringent
wines to give tone to the stomach, and these but little diluted, in order to dissipate and clear
away the other humours; for thirst is engendered by salty things.

Biography
Further
reading

Author Alexander Aphrodisiensis, 2nd –3rd cent. AD

Images

Anatomy
Pathology
Physiology He emphasizes the fact that kidney function influences the whole body, while that of other
organs, e.g. bones, muscles, veins affects a particular part of it. He states that blood has four
varieties. The thicker that is captured in the spleen, the even thicker that is excreted with the
faeces and the clear blood that is used as a nutrient for the body
Chemistry
Disease He repeated the reasons for the different location of stones in younger and older patients.
Therapy
Technical
General Two treatises have come down to us, which have been ascribed to Alexander Aphrodisiensis, of
Comments Aphrodisias, in Caria, and the most celebrated of the commentators on Aristotle.
Biography
Further
reading

10

Author Oribasius Pergamenus, 4th cent. AD

Images (SEE ATTACHED FILES)

Anatomy Oribasius in the 4th century was the first to recommend a truss for hernia, to describe the
Pathology function of prostate and the rectal muscles and lastly, to treat hypospadias.
Physiology He repeated Galen’s thesis about the shape and role of the kidney in separating urine form
blood and he added the precise statement that the whole amount that is secreted from the renal
granules is then excreted as urine, while the remaining clear blood feeds the whole body.
Chemistry
Disease He commented widely on other writers’ works, mainly Rufus’s. He accurately epitomized the
thesis that generalized oedema may be caused either by an excess of whole body fluid, or by
ailments of the liver (cirrhosis?). Equally successful was the explanation that thick substances in
the urine appear when the pores of the renal sieve (finistrae?) are damaged and become wider,
allowing thicker than normal material to pass through.
Therapy He devotes a large part of his works to the dietary importance of many foods in facilitating or
obstructing the normal function of the kidneys. Moreover he repeats the usual methods of the
past, like venesection.
Technical
General
Comments
Biography Oribasius (c. 320-400) was a Greek medical writer and the personal physician to the Roman
emperor Julian the Apostate. He was born in Pergamum of Mysia and established Byzantine
nephrology. He studied at Alexandria under Zeno of Cyprus before joining Julian's retinue. He
was involved in Julian's coronation in 361, and history has it that in 362, on behalf of his
emperor Julian the Apostate, Oribasius visited the Delphic oracle, now in a rather desolate
state, offering his emperor's services to the temple and, in return, receiving the very last
prophecy by the Delphic Pythia, announcing the final death of the Olympic pagan religion. He
remained with the emperor until Julian's death in 363 AD. In the wake of this event, Oribasius
was banished to foreign courts for a time, but was later recalled by the emperor Valens.

Oribasius's major works, written at the behest of Julian, are two collections of excerpts from the
writings of earlier medical scholars, a collection of excerpts from Galen and the Collectiones, a
massive compilation of excerpts from other medical writers of the ancient world. The first of
these works is entirely lost, and only 25 of the 70 (or 72) books of the Collectiones survive. This
work preserves a number of excerpts from older writers whose writings have otherwise been
lost, and has thus been valuable to modern scholars.

Further Renal and Glomerular Circulation according to Oribasius (4th Century)

reading Eftychiadis, A.C.
Am J Nephrol 2002; 22:136-138 (DOI: 10.1159/000063751)
Article (PDF 105 KB)
http://www.ub.unibas.ch/kadmos/gg/pic/gg0350_007_txt.htm

11

Author
Nemesius of Emesa, 4th cent. AD
Images
Anatomy
Pathology
Physiology He repeated Alexander’s theories about the four elements of blood
Chemistry
Disease
Therapy
Technical
General A Christian philosopher, apologist, and bishop of Emesa (now Hims, Syria) who was the author
Comments of the treatise: “On the Nature of Man” (Peri physeos anthropou, in Greek:), the first known
compendium of theological anthropology with a Christian orientation. The treatise considerably
influenced later Byzantine and medieval Latin philosophical theology.
Biography A man of extensive culture, Nemesius integrated elements from various sources of Hellenistic
philosophical and medical literature. He used the experimental physiology of the 2nd-century
Greek physician Galen and the observations of other men of science, the philosophy of
Neoplatonic Idealism (Alexandrian influence), and Aristotelian Realism (Antiochene influence).
The result is a Christian synthesis that cannot be characterized as representing any specific
philosophical school. “On the Nature of Man” lacks logical unity in its arrangement of material,
and its abrupt ending indicates that the work was unfinished or was intended for revision. The
opening chapter criticizes the concepts of man advanced by the Greeks from Plato to the 3rd-
century Christian sectarians; it then emphasizes the place of man in the plan of creation as
delineated in the Mosaic literature of the Old Testament and in the letters of St. Paul. Because
man bridges the spiritual and material worlds, Nemesius maintains, he requires a unique
intelligent principle of life, or soul, proportionate to his dignity and responsibility. He submits that
the soul must be an incorporeal, intellectual entity, subsistent in itself, immortal, and yet
designed to be one with the body.

Further Nemesius Of Emesa." Encyclopædia Britannica. 2006. Encyclopædia Britannica Premium

reading Service. 13 July 2006 <http://www.britannica.com/eb/article-9055234>.

De Natura Hominis. Liber Unus, Denvo Recognitvs et Manuscriptorum Codicum Collatio

12

Author Palladius Alexandrinus, 5th cent. AD

Images

Anatomy He states that the kidneys lack nerves, and thus do not feel pain. They may only feel a
Pathology heaviness and discomfort, if there is stone in their flesh. If the pain is excruciating, it means
that the stone has moved from inside the kidney to neighbouring areas.
Physiology
Chemistry
Disease He greatly elaborates on Hippocrates’ description and pathology of renal lithiasis. He
differentiates the causes of renal stones in children and adults and he clearly states that by the
term “nephritis” we usually mean renal lithiasis.
Therapy Apart of the usual to Byzantine doctors’ recommendations, he elaborates on Hippocrates’
instruction to use gymnastics and running to prevent and/or treat renal lithiasis and to combine
them with a light diet.
Technical
General
Comments
Biography Palladius, Greek doctor and sophist (iatrosophista) of the 5th century A.D. who lived and
worked in Alexandria. Writer of small medical treatises (synopses) and comments on
Hippocrates works (scholia).
Further reading

13
Author Alexander Trallianus, 6th cent. AD
Images
Anatomy
Pathology
Physiology
Chemistry
Disease There is again a treatise on differentiating renal form intestinal colics. He describes in detail the
clinical findings of generalized oedema and, interestingly, the persistence of the mark of the
finger after the pressure on the flesh is lifted. He discusses the pathogenetic mechanism of an
infection which he identifies with excessive blood accumulation, but he also emphasizes that it
is not only the amount of the accumulated blood but also its foul quality to be blamed.
Generally, he is a compilator.
Alexander put forward the hypothesis that renal stones are formed in cases of “thick humours
accumulated in the kidneys.”
Therapy He presents many compound medicaments as painkillers in renal lithiasis, describing the exact
dose of their ingredients. He also strongly recommends baths for the same infliction.
Technical
General
Comments
Biography Alexander Trallianus, (c. 525 – c.605) was a Greek physician born in Tralles in Lydia (now
Turkey). He lived probably about the middle of the 6th century and practised medicine with
success at Rome. The Greek text of one of his works was printed in Paris in 1548 and his De
Lumbricis at Venice in 1570.
Further
reading
 14

Author Aetius Amidanus, 6th cent. AD

Images

Anatomy
Pathology
Physiology
Chemistry
Disease He differentiates between intestinal and renal pain, repeats what already has been written about
diabetic nephropathy, describes some symptoms that may be assigned to chronic renal failure,
like lack of pain, occasional fever, emancipation, recurrent haematuria, faintness and
paroxysmal blindness. If nephrosclerosis coexists, anasarka oedema would appear. The
aetiology of lithiasis and haematuria after stress is discussed as also that of stone formation.
He described orchitis and testicular carcinoma, classified renal stones, classified three different
types of hydrocele and advocated the surgical drainage of renal abscesses.

Therapy He describes the mode of action of several herbal drugs used in renal ailments. He refers to the
venesection and various purgative measures, emphasizing the beneficial role of vomiting. He
recommends diuretics for the treatment of diabetes. A pleasant instruction was the moderate
use of wine by the elders.
Technical
General Aetius Amidanus, in the 6th century AD, returns to the old belief in the healing power of the
Comments humidity of statues in gyms – Christianity has in parallel promoted the collection of hallowed
moisture (agiasma) from relics, buildings and various objects associated with certain saints. The
same author repeats Orivasius’ opinions on the right colour of urine before training and on the
freedom of athletes to consume larger quantities and more nutritious food than common
mortals. However, his reference of the blindness due to nephropathy may be linked with the
current knowledge of several occulorenal syndromes, or the sudden blindness due to
intraocular pressure because of anasarca oedema and/or hypocalcaemia.
Biography
Further
reading

15

Author Stephanus Alexandriensis, 7th cent. AD

Images

Anatomy
Pathology
Physiology
Chemistry
Disease
Therapy
Technical
General
Comments
Biography Greek mathematician and philosopher of the 7th c. A.D., who taught in the university of
Constantinople (established by the Byzantine Emperor Theodosius II, 401-450 A.D.) during the
era of Emperor Heraklius. Reputably, he was a pupil and co-worker of the renowned doctor
Theophilus. It’s very likely that Stephanus did not practice medicine himself. He wrote many
treatises however, ‘memoranda’ on Hippocrates, Galen and Aristotle’s works as well as
various works on philosophy and astronomy.

Further reading

16

Author Paulus Aegineta, 7th cent. AD

Images
Anatomy
Pathology
Physiology
Chemistry
Disease Another compilator. However, he tries in an apologetic fashion to explain why Hippocrates did
not write a whole disease on the renal problems but left only scattered fragments on them. He
brilliantly puts forward some etymological explanations about the identical terms used for
different renal problems and their causes, like phlegm, nephritis, colic, nutrient and heaviness.
These explanations are not always correct but underline the ancient Greek writers’ feeling of
inaccuracy in their descriptions of kidney diseases.
Therapy He presents a long list of herbal remedies for kidney diseases, used either internally or
externally. Some of his drugs are quite exotic, like the blood of a male goat or the dried
decapitated bodies of cicadas.
Technical
General
Comments
Biography Paul of Aegina or Paulus Aegineta (625? –690?) was an Aegina-born 7th-century ancient Greek
physician best known for writing the medical encyclopaedia Medical Compendium in Seven
Books (in Greek: Epitomes iatrikes biblia hepta). For many years in the Byzantine Empire, this
work contained the sum of all medical knowledge of the then known world and was unrivalled in
its accuracy and completeness.

The sixth book on surgery in particular was referenced in the European and the Arab worlds
throughout the Middle Ages and is of special interest for surgical history. The whole work in the
original Greek was published in Venice in 1528, and another edition appeared in Basel in 1538.
Several Latin translations have been published and it was first translated into English, with
commentary by Dr. Francis Adams sometime between 1844 and 1848.

He remained in Alexandria after the Arabic invasions. He was called by the Arabs Al Qawabily,
which means the Gynaecologist, because he described in detail the male and female genitalia.
He also performed exclusively therapeutic orchiectomy and surgically treated hydrocele and
vericocele. His writings and his works particularly influenced the Arabians who studied and
translated them. He studied and practiced at Alexandria and also at Rome.

The whole work in the original Greek was published in Venice in 1528, and another edition
appeared in Basel in 1538. Several Latin translations have been published and it was first
translated into English, with commentary by Dr. Francis Adams sometime between 1844 and
1848.
Further For his medical writings as they were known in Arabic, see Ullmann, Medizin, pp. 86-87; Sezgin
reading GAS III, p. 168-170. For an English translation of the medical encyclopaedia by Paul of Aegina,
see, The Seven Books of Paulus Aegineta, trns. by Francis Adams (London: Sydenham
Society, 1844-1847).

17

Author Theophilus Protospatharios, 7th cent. AD

Images A manuscript illustration in MS 3632, FOL. 512, Un. Bologna, depicts him sitting, while his
assistant Plossos fetches him a uroscopy bottle in a special canister. An array of vials with
several urine colours is lying at he bottom of the illustration.

Anatomy He repeats the ideas on the subject by previous writers.

Pathology
Physiology
Chemistry
Disease He described the various findings from uroscopy according to the patient’s particular tissue
damage. He elaborates on Hippocrates’ comment that if the perirenal fat is melting away, the
urines will have an oily appearance. He presents - in between other comments - a list of the
various renal problems of the elderly, in an imaginary dialogue between himself, Stephanus
Atheniensis and Damascius.
Therapy
Technical A similar report with Actuarius comments on the heating of urines can be found in the writings
of Theophilus Protospatharius (7th c. AD): “So what must be learned is that in all kind of urines
we inspect four qualities, the composition of the urines, its colour, the substance and the
solutes; [...] And the ones that become thick not from the inside [of the body] but because of
the cold air, will become thin again when warmed in warm water […]”
General He was the most important uroscopist of Byzantium until Johannes Actuarius, four centuries
Comments later.
Biography He lived between the 6th and 7th centuries A.D. in Constantinople. Doctor in the court of
Emperor Heraklios, he was given the title of Protospatharios (leader of the imperial guard but
also a honorary title). He wrote, among other works, the treatise “de urinis” (“peri ouron”) one
of the most influential works on uroscopy.

Further reading Theophilus Protospatharius and Damascius. Commentarii in Hippocratis aphorismos. In: Dietz
FR, editor. Scholia in Hippocratem et Galenum. Amsterdam: Hakkert, 1966: Volume 2, page
446, lines 6-17.

18

Author Stephanus Atheniensis, 9th-10th cent. AD

Images

Anatomy
Pathology
Physiology
Chemistry
Disease
Therapy Again the usual recipes and also the eating of beetles as diuretics.
Technical An important test found in Byzantine texts is that of the warming of urines. Byzantine doctors
had noticed that the external temperature was very important for the proper inspection of
urines. The cooling of the urines had a corrupting result on the diagnostic and prognostic value
of uroscopy; therefore they had invented a method of partially reversing the effects of cooling.
They would reheat urine in the amis and record the occurring changes. This technique was
thought to be introduced during the 19th century AD (19) by Richard Bright but, as the following
passages show, it seems that it was a rather common procedure found in several texts from
different centuries. Stephanus (7th-9th c. AD?) recalls the use of this technique in order to
differentiate the “thickening” of the urines that is due to the cooling from the environment from
that attributed to the existence of thick substances in the urines: “[…] if it [the urine] came like
this from the body then it will remain like this, or else [if the condition is reversed] it will become
thin again. For if it was not created thick inside, but it was urinated thin and became thick
because of the cooling of the air, like the crystals, if put either in fire or in warm water becomes
thin again, or else it will also show bubbles on the surface and that means that it is thick due to
its composition […]
General
Comments
Biography
Further reading

19

Author Damascius, 9th-10th cent. AD

Images

Anatomy
Pathology
Physiology
Chemistry
Disease He is involved in an imaginary dialogue with Protospatharius and Stephanus Atheniensis. In it,
he mainly describes symptoms of lithiasis and elaborates on the causes of strangury.
Therapy
Technical
General
Comments
Biography We know very few things about him. He is known as a commentator of Hippocrates and Galen.
No other works are attributed to him. He lived before the 11th c. A.D. He is a different person
from Damascius the philosopher and neo-Platonist of the 6th c. A.D.

Further reading

20

Author Pseudo-Galen
Images Pictures of workers from the Book of Antidotes of pseudo-Galen. Probably Northern Iraq 1199,
The Red Kaganate, Turko-Mongol Trousers
By Steven Baker, http://www.geocities.com/kaganate/pants2.html
http://www.mcah.columbia.edu/cgi-bin/dbcourses/item?skip=10500, Item ID:10686
Anatomy He describes the direction of the renal arteries from the abdominal artery to the kidney. He
Pathology rightly comments that the reason for the many minute vessels in the kidneys is the delay of the
blood inside them, thus to permit for the separation of the blood from urine.

Chemistry
Disease He comments in detail on Hippocrates’ Aphorism that tuberculosis may inflict the kidneys. He
hypothesized that because of their narrow urethral passage, children are prone to develop
bladder-stones, while old people with a wider urethral passage form kidney stones, having
enough space in there for stones to be formed. He reported an earlier observation by Diocles
that a lung abscess may be drained via the kidney to the urines. And he also correctly states
that an enclosed renal infection (abscess) may cause a lot of pain but doesn’t present any sign
form the urines. On the contrary, when it drains there are obvious uroscopical findings.
Therapy
Technical
General
Comments
Biography
Further
reading

21

Author Michael Psellus, 11th cent. AD

Images

Anatomy
Pathology
Physiology
Chemistry
Disease He wrote an extensive poem on medical problems with more than one thousand verses, which
he titled himself without excessive modesty, as “An excellent medical work in the iambic
manner, by the wisest Michael Psellus” Many of its verses are devoted to a brief presentation
of symptoms and findings of renal ailments, as well as their therapy.
Therapy
Technical This knowledge isn’t delivered to some specialized physicians, but to any cultured man:
“…Because the varieties of the [urines’] mixtures are many, and my judgment and the purpose
of the verses is not to contain all of everything of the art, but to provoke the appetite of my
fellow men, scholars, rhetoricians and philosophers, on the accurate art of medicine, because
as their are pursuing the (metrical) graces of the rhymes, in metrical (doses) they will conceive
the (medical) art. So these are enough about the urines…”. However, Psellus’ likening of the
method of uroscopy with the oracles spelled by the Delphian priestess Pythia was repeated,
albeit scornfully, six centuries later. James Hart, writing in 1623, states: “Hence, it comes to
pass that any idle old trot cobbler, or costard-monger, will seem to pronounce some Delphian
oracle by the urine.”
General There are poems on uroscopy and extracts from correspondence, not by medical doctors but
Comments by literati from various disciplines, give many details about urines in health and disease.
Because the prognosis of disease, as Michael Psellus suggests in such a poem, does not
 depend on physical examination alone: “…for one can guess the future of the disease not by
the beat of the pulse but by the stools and the multicoloured qualities of the sputum, and the
observation of the urines is often adequate to show the future like the Pythian Tripod”
Biography Michael Psellus (11th c. AD) the politician, diplomat, poet, with an extended medical knowledge
Further reading Diamandopoulos AA, Diamandopoulou AH and Marketos S. Two Late Byzantine songs on
Uroscopy and Phlebotomy. Rivista di Storia della Medicina, Societa Italiana di Storia della
Medicina, 1996

22

Author Symeon Seth, 11th cent. AD

Images

Anatomy
Pathology
Physiology
Chemistry
Disease
Therapy Symeon Seth, recommended exotic drugs for the treatment of urological problems.

Technical
General
Comments
Biography He was active in the 10th century. His treatise on drugs exemplifies the Byzantine doctors’ of
the period trend to introduce new therapeutic substances from foreign lands.
Further reading

23

Author Johannes Apokaukos, 13th cent. AD

Images

Anatomy
Pathology
Physiology
Chemistry In a passage of one of his letters to a fellow bishop Apocaucos describes in the year 1219 AD
the stones that he painfully urinates: “… and I also suffer chronic disease from my kidneys for
there are stones that come through the glands of my penis, sometimes big like grams, only
heavier, and have many shapes. And they are polygonal and like pyramids or cubes. And
because of the different shapes they hurt the lumen of the urethra and cause extreme pains
and sufferings. And some other times when they are big enough they completely block my
urethra and I’m completely filled with liquids. And by tearing the lumen it causes such pain,
bringing death before my eyes…”. The description was so accurate that we observe its
repetition, almost verbatim, by Van Swieten, an elaborated scientist of the 18th century (i.e.
after the invention of the microscope), when he described a deposit in the urine “of crystals
having a figure of rhombus”.
Disease
Therapy
Technical
General
Comments
Biography He was Archbishop of Naupaktos and Arta, in Southwest Greece during the era of the partition
of the Byzantine Empire after the 4th Crusade. The Crusaders occupied the main part of the
Empire, while three minor Greek States had been established in the periphery. Two in Asia
Minor (the Empires of Nicaea and Trabizond) and one in Northwest Greece (the Principality of
Arta). Apocaucos, scion of a celebrated Byzantine family, became Archbishop of Naupaktos
and thus Prelate of the Principality of Arta. He developed a remarkable activity both in the
administration of the Church and the State. He was an accomplished epistolographer and
more than a hundred of his letters survive.

24

Author Nicolaus Myrepsus, 13th cent. AD

Images The 14th century frontispiece of the Dynameron manuscript. On the upper zone Christ is
depicted enthroned, flanged by Virgin Mary, St. John the Baptist and the Archangels. On the
lower zone the Chief-Physician is examining a uroscopy bottle, here in Athens, while his
patients are waiting for an answer.

Anatomy
Pathology
Physiology
Chemistry
Disease
Therapy Nicolaus Myrepsus was the author of the celebrated pharmacological book “Dynameron” that
contains many drugs with nephrological action.

Technical
General
Comments
Biography
Further reading

25

Author Johannes (Ioannis) Zacharias Actuarius, 14th cent. AD

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Anatomy
Pathology
Physiology Similarly to the method of his predecessors in uroscopy, Johannes explained all the
changes of the colour, sediment, transparency and general appearance of the urine to the
 imbalance of the four humours. He added many interesting arguments about the role of the
waste products of metabolism during the various phases of the disease. Thus, he came to
observe correctly signs and symptoms that may be correlated to day with an array of
ailments, while he himself did not really know the exact nature of the disease. As examples
may be presented his description of what we now call secondary hyperparathyreodism,
adipose tissue wasting, acute nephritis and many others. A pitfall of his theories was
considered his remarks about the findings of the urines in ailments of a particular organ, e.g.
the brain or the bones. This can be explained by the general tendency of medieval
uroscopists to explain everything via their method, in spite the fact that Johannes was very
careful to avoid the overestimation of uroscopy. It is tempting to speculate today, with the
current knowledge of proteomics, that the link between laboratory findings of the urines and
diseases of particular organs isn’t just a medieval doctor’s fancy.
Chemistry
Disease He recommends eating fruits and mainly of figs and grapes as purgatives for the kidneys.
For the same purpose he also suggests almond-oil.
Therapy
Technical Actuarius is acclaimed for his introduction in uroscopy of a vial with specific characteristics.
These were the flat basis, the high quality of translucent uncoloured glass with a smooth
unadorned surface and grid marks. He also elaborated further on the importance of the
urine’s temperature when this were examined, suggesting the heating of them by immersing
the container in a bath of boiling water, a kind of bain marie. This was an astonishing
observation more than half millennium before Richard Brights’s description of the urine’s
coagulation by heating in the case of proteinuria.

The following passages from his treatise on urines show his meticulous scientific thinking:
“Chapter a. […] But first of all we must investigate the amis and the place and the time in
which the inspection of the urines is proper to be done; […] So those amides that are made
of transparent and thin glass can show the exact colours. Some that are slightly green, and
being so, they are not exactly transparent – because the transparency is the result of the
absence of colour – deprive some of the colour and maybe of the composition. And through
them the contents cannot be seen exactly because of the impurities. And since they [the
impurities] have various shapes, they corrupt the diagnosis. And if it also happens that they
[the amides] are very wide and the urine sample is minimum and is spread on the bottom
and is only slightly deep, there is no way to distinguish the impurities. And as for those
amides that are made asymmetrically, having thinner tops and wider bottoms, and having
the bottom protruding, since they have large volumes they can collect all the urine and thus
seem useful for carrying. But as their usefulness for inspection of the urines is concerned,
they are notably at disadvantage compared to the other amides, which have the shape of
the drinking glasses and are very useful and the most useful of the shapes you must learn
[...]. Now we shall talk on the inspection of the urines.
Chapter b. On the proper place in which the inspection of the urines must be done. Because
the more shadowy places remove a part of the colour making it darker and the more sunny
and luminous make the colours seem softer, one has to inspect in both conditions and by
eliminating the colour effect and trying to find the median condition, so that he will not
misjudge any of the colours. And if he can see the contents clearly this is good enough. But
if they are still very dim and not obvious, then he must look at them against the sun to see
them clearly. And it is also useful to know the time at which it is better to inspect the urines
 […]
Chapter c. On the timing that is more proper to inspect the urines.
So, when the urines that are micturated in the amides are still felt lukewarm they give the
exact colour to our sight, but the contents and their composition and the bubbles that are
attributed to them, naturally, are not yet clearly seen. Because some of the bubbles will
disappear, following the loss of temperature, while some others will remain as the urines get
cooler. And the suspending particles at the beginning will not be seen well, but as the urine
get cooler then these also start to appear more clearly, as they might be cloudy or, as time
passes, either remain as they were or start to move to the middle of the amis and then to
the bottom. And as for the compositions, those that are distributed equally are recognized
by the colour, those that are thick are demonstrated after the suspending particles deposit,
and later these deposit as well. Therefore it is useful to observe the urines not after they are
already cold or you will make great mistakes in your diagnosis, but also be careful not to
shake them much before you inspect them for you will move the particles and destroy the
bubbles and dilute the deposits and confuse the situation. And these are about the timing
that are necessary to know for the exact inspection of urines, in accordance to the exact art
of those who know […]” (17).
Actuarius, in the same book, “De urinis”, often refers, some times scornfully, to the
specialists who inspect the urines. He does not refer to them as “doctors”. He uses the
terms “urine inspector” and “nature inspector”, terms, which imply the existence of a
separate specialty of the “inspector”, sort of a laboratory technician: “[…] But it is not so
when one sees thin urine during the winter and is unable to overcome the cold weather, and
during the summer, thick [urine] and is unable to stop the dilution due to the heat. So what
do the respectable urine inspectors think when they see thin urines that become thick the
next day, and the opposite, despite the climate? How can they tell when the change took
place and for what reason? It seems to me that they mistake, being far from the truth […]”
And in another passage concerning the effect of the food consumed on the qualities of the
urines, we read: “ […] so that the nature’s inspector will see all these by the norms of
colours and compositions and particles, and by examining the proportions in each one of
them and decide what to do, maybe this way he will not make a mistake […]”

General Actuarius had been initially enrolled to be an orator, but later decided to become a medical
Comments doctor, as he found medicine a practical way to help people, while rhetoric was just an
exhibition of haute eloquence, without any benefit to humanity apart of self-admiration. In
spite of his contempt for flowery speaking, he sometimes went astray to the fields of a rather
poetic way of writing medial text, as he himself sincerely admitted. Although his writings
reveal him as pragmatic scientist without the usual medieval assumptions, he unashamedly
stated at the beginning of his treatise on urines that he aimed to complement Galen,
Hippocrates and the rest of ancient medical writers, as they have left only uncompleted
works on the subject. He tried successfully towards this end.
His main contribution is that not only did he describe the various differences of the colours
and other characteristics of the urines according to various increases, but also tried to
explain the pathological mechanisms via which these differences did occur. Although he
must have had knowledge of Avicenna’s Canon on Urines, he elaborated much further. This
interaction between Byzantine and Arabic, Syrian and Iranian medicine is well documented,
especially during the era of Late Byzantium.

Biography Johannes Zacharias Actuarius (c. 1275-c. 1328) was a Byzantine physician in
 Constantinople. He wrote several books on medicinal subjects, particularly, an extensive
treatise about the urines and uroscopy. Around 1299, he considered moving to
Thessalonica, Northern Greece, but decided to stay in Constantinople; later, he was
appointed chief physician to the Emperor. Actuarius was a title at the court of
Constantinople, given apparently only to physicians, and quite distinct from the use of the
word found in the earlier Latin authors, but has come to be associated with Johannes. The
name Zacharias, meaning ‘sugary’ was also a nickname given because of his sweet
speaking. Thus, the only solid information we have about his name is Ioannes. He sided
himself with the party of the Emperor Andronicus Paleologos and the Great Duke Alexius
Apocaucos during the Byzantine internal conflicts of that period. He made a number of
important contributions to clinical medicine and generally followed the teachings and tenets
of Hippocrates and Galen. The first portion of this work was translated from the Greek by
Corneille Henri Mathys (d. 1565) and is a systematic textbook of medical practice.

In "On the functions and disturbances of the soul-spirit," Actuarius discussed a number of
different mental illnesses that could be attributed to dietary errors, bodily causes, fatigue,
and intemperance. For patients so afflicted he prescribed diets, baths, and exercise. He
considered the origin of the soul to be in the pneuma, which was formed in the liver and
united with the vital spirit in the heart for distribution throughout the body. He recognized five
mental functions that distinguish man from animals: reason, understanding, judgment,
perception, and imagination. "On the urines" was an influential book and had a significant
impact on medicine of the Middle Ages.

However, in contrast to later physicians, Actuarius placed great emphasis on the fact that
uroscopy was only one method to be used in determining a diagnosis. He thought that urine
was a filtrate of the blood and, as such, could be analyzed to provide reliable information in
pathological conditions. He recommended that the physician employ a graduated glass
vessel as an aid in examining the urine. Actuarius also made one of the earliest reports of
haemoglobinuria in this work. Volume II contains the six books of his Methodi medendi here
translated by Mathys. It is in this general treatise on medical practice that Actuarius reveals
his active practice of Hippocratic principles. He believed in treating each case on its
individual merits and spoke out against the polypharmacy of his day. Although an adherent
of Galen, he did not always agree with him and he was successful in making Galen's
teachings on the pulse clearer and easier to follow. He felt that venesection was of great
therapeutic value and provided specific guidance for the best areas to let blood for various
disease states. He was perhaps the first to detect and describe the pinworm and also wrote
on colic and lead poisoning. Volume III contains his Composition of medicines here
translated into Latin by Jean Ruel (1479-1537). In this comprehensive treatise, Actuarius
discusses a wide variety of therapeutic agents, their uses, actions, and directions for
preparation. In addition to this treatise, there are three works by Sylvius in the volume:
Commentarius in Claudii Galeni duos libros De differentiis febrium (see No. 182), De
febribus commentarius (see No. 178) and De mensibus mulierum et hominis generatione
(see No. 184).
Further reading

26
Author Nicephorus Vlemmydes, 14h cent. AD
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Anatomy
Pathology
Physiology
Chemistry
Disease
Therapy
Technical His most well known nephrological writing is a huge poem on the colours of urine, which was
supposed to be sung by the medical students in Constantinople. It is now presented only a
small passage in a translation by the author: The Canon which distinguishes between the
thirteen uroscopy vials that are examined for human diseases, and also includes the most
necessary instructions for both their diagnoses and treatments.

Prelude:
Three linear hymns (sound A') to be chanted to the rhythm of the canticle "of the celestial
battalions"
Be aware that there are thirteen vials in different diseases,
first comes the white, second the blond and third the pinkish;
the fourth is reddish and the fifth is like blood,
the sixth is identical to saffron.

After the latter be aware that the seventh is similar to citron,

and the next is black and the ninth is white just like water;
the tenth is off-white with sediment and is totally turbid as is the eleventh.

The appearance of the twelfth is not stable;

neither turbid nor clear, but seems to be just as
a stirred mixture and is therefore muddy; the last one
is saffron-like. Well, try then and learn herein their proper diagnoses […]

In his popularized poem, Nicephorus Blemmydes describes a test (that reminds us of a similar
modern test of the three sequential urinations) for diagnosing the seriousness of the illness:
“[…] and if it derives from the stomach [the disease], because of indigestion, go and collect two
and three bottles in a row and learn their interpretation. And if they remain the same then this
means death. But if they change to clear or yellow then the patient will become healthy
again…”
General
Comments
Biography He was born in 1197 A.D. at Constantinople, died in 1272 at Ephesus. Theologist and
philosopher, studied at Prusa and at Nysse of Bithynia. He wrote several works on alchemy,
geography and an epitome on logic and physics. He also wrote two autobiographies, which are
considered major historical sources for his era. His main contribution in nephrology is his poem
“On Urines” (In Greek: “Peri uron”)
Further reading